Leveraging the Clinical Laboratory
in the Accountable Care Era
James M Crawford, MD, PhD
Senior Vice President for Laboratory Services North Shore-LIJ Health System
Chair, Department of Pathology Hofstra North Shore-LIJ School of Medicine
Manhasset, NY
♦
Leveraging Clinical Laboratory Data
in the Accountable Care Era
James M Crawford, MD, PhD
Senior Vice President for Laboratory Services North Shore-LIJ Health System
Chair, Department of Pathology Hofstra North Shore-LIJ School of Medicine
Manhasset, NY
♦
Association of American Medical Colleges (AAMC)
2009-2013 Chair sequence, Council Acad Societies
Association of Pathology Chairs (APC)
2010- “anything that moves”: ACO, Health IT
College of American Pathologists (CAP)
2010- “anything that moves”: ACO, Health IT
Biomedical Research Alliance of New York (BRANY)*
2009- Vice Chair, Managing Committee
*CRO for Clinical Trials
Disclosure
Drivers of Healthcare Reform
3/2009: American Recovery and Reinvestment Act
3/2010: Patient Protection and Affordable Care Act
HITEC
ACO
2009 2010 2011 2013….
Electronic Health Records, Meaningful Use
Physician Network Consolidation:
Private Payers, Employers…
Shared Risk → Full Risk
ACOs PCMH
6/2012: Supreme Court
2012
The Changing Healthcare
Delivery Landscape
The Changing Healthcare
Delivery Landscape
How is Pathology going to play a role?
NSLIJ: The Road to Success
NSLIJ Labs: The Car-in-Front
● ●
●
●
●
●
● ● ●
● ●
●
●
●
● ●
●
●
Hospitals (26% of market) Reference laboratories
200+ practice locations Network of SNFs
Core
Lab
Huntington Forest Hills
Franklin Glen Cove
Southside
Syosset
Plainview
Manhasset
LIJ
SIUH
North
Physician’s Offices
Nursing Homes
Clinical Trials BARC
Non-System Hospital
Reference Testing
Outreach
Hospital Lab
RRL
Centralized Laboratory Network
Current (CLN)
Staten
Island Lab
SIUH
South
NJ, Brklyn, SI
Physician’s Offices
Nursing Homes
LHH
Core
Lab
Huntington Forest Hills
Franklin Glen Cove
Southside
Syosset
Plainview
Manhasset
LIJ
SIUH
North
Physician’s Offices
Nursing Homes
Clinical Trials BARC
Non-System Hospital
Reference Testing
Outreach
Hospital Lab
RRL
Centralized Laboratory Network
Current (CLN)
SIUH
South
NJ, Brklyn, SI
Physician’s Offices
Nursing Homes
LHH
Quest
SIUH Dept of Pathology & Laboratory Medicine: Pouch Terminal
SIUH Dept of Pathology & Laboratory Medicine: Pouch Terminal
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
200000
14
NSLIJ Pathology and Laboratory Medicine
Surgical Pathology Cases/year: 2012
North Shore-LIJ
Mount Sinai Medical Center – New York
The Ohio State University The Cleveland Clinic
University of Pittsburgh
Mayo Clinic
SIU
H
Co
mm
un
ity
Co
re +
NS
+ L
IJ
LX
0.0
5.0
10.0
15.0
20.0
25.0
15
NSLIJ Pathology and Laboratory Medicine
Clinical Laboratory Tests/year: 2012
North Shore-LIJ
Henry Ford Mayo Clinic
The Cleveland Clinic Mill
ions
SIU
H
LX
C
om
m
Co
re-N
S-L
IJ
Your “Value” as a Laboratory
Competitive Cost Against the largest national labs
Safety and Quality The highest standards
Service Delivery To Patients
To Healthcare Providers
Data Delivery To the Electronic Health Record
To Providers (? Mobile Apps ?)
To Patients (Patient Portals)
Data Analytics Managed Care Contracting
Hospital Expense Management
Healthcare Delivery
Patient Outcomes
Total $2.5 T
Hospital care $661 B ($44B Hospital Lab)
Physicians $320 B
Drugs $235 B
Dentists $ 94 B
Outpatient Care Centers $ 43 B
Physician Imaging $ 38 B
Outpatient Hospital Imaging $ 25 B
Medical and Diagnostic Labs $ 18 B (“In Vitro Dx”)
Dental Labs $ 4 B
Behavioral Health $ 2 B
Research $ 44 B
The Costs of Healthcare: 2010
NSLIJ Labs
Independent &
Physician Office
Labs
Hospital Labs
Quest
LabCorp
12%
8%
10% 62%
National Laboratory Market = $62B*
$302M; 0.5%
*Laboratory Industry Outlook 2011, G-2 Report
Total POLs
Laboratories Registered 232,996 116,634
Waiver 153,568 66,903
Provider Performed Microscopy 37,299 29,875
Compliance (CMS surveys) 19,354 12,597
Accreditation 15,658 5,704
COLA* 6,463
CAP 5,728*
The Joint Commission 2,380
AABB 122*
American Osteopathic Assoc 128
American Soc Histo Immuno 122
*Commission on Laboratory Accreditation *our “universe”
CLIA Database 2012
Bioreference Lab
NSLIJ Labs
Sunrise (Sonic USA)
Enzi Other
Quest
LabCorp
30%
6%
6%
4%
5%
40%
10%
Downstate New York Outreach Market = $1.2B
$104M (9%)
Managed Care
Opening Gambit “Exclusive contract with national lab”
Clawback Negotiating back to a “Carve-In”
Managed Care
Opening Gambit “Exclusive contract with national lab”
Clawback Negotiating back to a “Carve-In”
How?
Financial Performance Contribution to Health System
Costs Hospital savings
Cost-per-Test
Client Service Patient Experience
Physician Satisfaction
Support of ACO Coordinated Care
Patient Outcomes
Overall cost of Healthcare
Cost-per-Test
Salaries and Benefits
Reagents
Rent and Utilities
Repairs and Maintenance
Depreciation
Other
Cost-per-Test
Salaries and Benefits
Reagents
Rent and Utilities
Repairs and Maintenance
Depreciation
Other
VOLUME → Productivity → Efficiency
Lab Revenue vs. Cost
Fee-for-Service system Revenue opportunity
Shared Risk/Full Risk “Medical Loss Ratio”
Cost and Utilization Management applies regardless of
Payment Model
(you also have to manage Revenue Cycle
during the transition)
Your “Value” as a Laboratory
Competitive Cost Against the largest national labs
Safety and Quality The highest standards
Service Delivery To Patients
To Healthcare Providers
Data Delivery To the Electronic Health Record
To Providers (? Mobile Apps ?)
To Patients (Patient Portals)
Data Analytics Managed Care Contracting
Hospital Expense Management
Healthcare Delivery
Patient Outcomes
Lab-run Phlebotomy Item Addressed Hospital
Management Laboratory
Management
Walk-in Blood Draw 8:00am – 5:00pm 6:30am – 7:00pm
Wait Time Complaints: > 20min <5min
Off-tower AM Draws 11am – 1pm By 9:00am
Off-tower INR Results Complaints By 11:00am
Staffing 4 Phlebomists 4 + 114* “flex”
*32 Patient Service Centers around region
Home Care
NSLIJ Core Laboratories: HOME PHLEBOTOMY DRAWS
200 per day @ 2.4 Tests/draw = ~ 500 tests/day →
>100,000 Tests / year on 40,000 patients
= 2% of our population of 1.6M unique patients
To what end, and with what benefit?
2012 Physician-Engagement Survey
1380 Physicians (16%) 16 hospital sites
300 Ambulatory sites
Pathology Services Highest ranked Ancillary service
Both “Client Service” and “Quality”
AP and CP
Laboratory Data Interoperability
Enterprise
EHR - Hospital E
nte
rpri
se
EH
R –
Am
bu
lato
ry
No
n-E
nte
rpris
e
EH
R –
Inp
atie
nt-A
mb
ula
tory
Laboratory Data Interoperability
Enterprise
EHR - Hospital E
nte
rpri
se
EH
R –
Am
bu
lato
ry
No
n-E
nte
rpris
e
EH
R –
Inp
atie
nt-A
mb
ula
tory
X X
X
Laboratory Data Interoperability
HIE*
Enterprise
EHR - Hospital E
nte
rpri
se
EH
R –
Am
bu
lato
ry
No
n-E
nte
rpris
e
EH
R –
Inp
atie
nt-A
mb
ula
tory
*Laboratory Information System *Health Information Exchange
*
* *
First: “Mobile Health”
Am J Public Health 1930; 20: 80-84
PCMH vs ACO
PCMH Practices
Mobile Health
Hospitals Emergency SNF, Rehab
Pharmacy, Laboratory, Imaging
Living at Home
Objectives:
Healthcare Providers
● Mobile “Apps” Synchronize smoothly with EHR
Capture all billable events
Capture all biometrics and medications
CPOE for Lab Testing
“Push” Lab Values out
Upload “right information” at “right time”
on “right patient” to “right provider”
Do not degrade patient-centered focus
Are secure
Your “Value” as a Laboratory
Competitive Cost Against the largest national labs
Safety and Quality The highest standards
Service Delivery To Patients
To Healthcare Providers
Data Delivery To the Electronic Health Record
To Providers (? Mobile Apps ?)
To Patients (Patient Portals)
Data Analytics Managed Care Contracting
Hospital Expense Management
Healthcare Delivery
Patient Outcomes
Personalized
Medicine
Patient Centered
Medical Home
ACO: Population-based
Healthcare Outcomes
HIT
Integrated Data: the Patient
Data Interoperability
current: Ambulatory EHR, Inpatient EHR, Laboratory, Claims, Medications
future: Emergency (EDIS), Imaging (PACS), Pharmacy, Dentistry
Laboratory must take initiative in driving interoperability.
Data Completeness
EHR = “structured data” → “meaningful use”
Data Access: Information at the point-of-care
Includes “Mobile Technologies” for laboratory data.
EXECUTION: The Care Plan
Access and input: multiple providers
Critical Pathway: the chronological order of execution
Integrated Data: the Population
Population Segmentation
by disease condition
by beneficiary coverage (contracts)
by Care Plans: What do your patients need, when, and in what order?
Population Reporting
Patient Registries
Population Metrics
How does our Laboratory Data inform Population Outcomes?
THE LEARNING HEALTHCARE SYSTEM
The best data is your own
Monitor your practice patterns and outcomes
Modify, innovate, improve
= Margin
The Race to the Bottom
= Margin
Rebalancing
Utilization
Interpretation
Care Coordination
Fee-for-Service Strong incentive for utilization
Shared Risk Utilization is a “cost”
We will have to justify Utilization of our services,
And “Valuation” thereof.
BUILD YOUR OWN STORY
Managed Care
